Posttraumatic Stress Disorder After Minor Trauma – a Prospective Cohort Study T

Medical Hypotheses 135 (2020) 109465

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Medical Hypotheses

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Posttraumatic stress disorder after minor trauma – A prospective cohort study T

Katharina Angerpointnera, Stefanie Weberb, Karen Tschechb, Hannah Schubertb, Tanja Herbsta, ⁎ Antonio Ernstbergera, Maximilian Kerschbauma, a Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany b AARU Audi Accident Research Unit, University Hospital Regensburg, Regensburg, Germany

ARTICLE INFO ABSTRACT

Keywords: Background: Posttraumatic stress disorder (PTSD) can arise as a reaction to a traumatic experience. While many Posttraumatic stress disorder data concerning PTSD in severely injured patients are available, little is known about this disease in slightly PTSD injured patients after road traffic accidents. It is rather assumed that PTSD does not exist after objectively slight Anxiety disorder injuries. Minor trauma Methods: In total, 36 patients (Injury Severity Score < 16) after road traffic accidents were included in this Road traffic accident prospective cohort study. Next to demographic and accident-specific data, the PDI (Peritraumatic Distress Inventory: individual experienced distress directly during or immediately after the traumatic event), THQ (Trauma History Questionnaire) and the BDI-II (Beck Depression Inventory-II: self-report measurement tool to examine the severity of depression) were assessed immediately after trauma (t0). Six weeks (t1) and 3 months (t2) after trauma the Impact of Event Scale – Revised (IES-R), a screening instrument for PTSD, and the BDI-II were collected. Results: Overall 2 patients showed critical measurement values in IES-R after 6 weeks. A strong correlation between PDI and IES-R at t1 and t2 could be detected (p < 0.05). Furthermore, a significant correlation of BDI- II and IES-R after 6 weeks and 3 months was found (p < 0.05). Neither age or sex showed a significant correlation to IES-R (p ≥ 0.05). Conclusion: The present study showed that symptoms of PTSD can also occur after minor trauma. Especially high peritraumatic distress is associated with developing a PTSD. The occurrence of PTSD should be considered not only in severely injured patients, but also in slightly injured patients after road traffic accidents.

Background hyperarousal. The symptoms have to last longer than one month, cause significant functional impairment and develop within the first 6 months Posttraumatic stress disorder (PTSD) is a widespread form of anxiety after trauma [2]. disorder. It arises as a reaction to the experience of a traumatic situation Many studies investigated possible influencing factors for devel- and a subsequent maladaptation. To diagnose PTSD according to the oping a PTSD [3–7]. The results showed that injury severity is not a Diagnostic and Statistical Manual of Mental Disorders, 5th edition good predictor of psychosocial outcome, whereas the subjective impact (DSM-5) [1], a patient has to experience a traumatic event and addi- of trauma is much more important in this context [7]. Recent studies tional symptoms from each of the following four symptom clusters: have shown that a traffic accident can be a triggering event for devel- intrusion (e.g. flashbacks, nightmares), sustained avoidance of trauma- oping PTSD [2,8,9]. The prevalence of PTSD in severely injured patients associated stimuli, negative impact on cognition/mood and ranges from 4.7% up to 34% within the first three months [10,11]. But

Abbreviations: AIS, Abbreviated Injury Scale; BDI-II, Beck Depression Inventory-II; DSM-5, Diagnostic and Statistical Manual of Mental Disorders, 5th edition; GCS, Glasgow Coma Scale; ICU, Intensive Care Unit; IES-R, Impact of Event Scale-Revised; ISS, Injury Severity Score; MAIS, Maximum Abbreviated Injury Scale; PDI, Peritraumatic Distress Inventory; PTSD, Posttraumatic stress disorder; SD, Standard Deviation; t, time; THQ, Trauma History Questionnaire ⁎ Corresponding author at: Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany. E-mail addresses: [email protected] (K. Angerpointner), [email protected] (S. Weber), [email protected] (K. Tschech), [email protected] (H. Schubert), [email protected] (T. Herbst), [email protected] (A. Ernstberger), [email protected] (M. Kerschbaum). https://doi.org/10.1016/j.mehy.2019.109465 Received 9 September 2019; Accepted 27 October 2019 0306-9877/ © 2019 Elsevier Ltd. All rights reserved. K. Angerpointner, et al. Medical Hypotheses 135 (2020) 109465 so far, this research was only focused on PTSD after severe injury and Table 2 polytrauma. The aim of the following study was to determine whether Timetable for data collection and questionnaire. ﬃ PTSD is likely to develop in lightly injured patients after road tra c t0: Immediate after trauma t1: 6 weeks after t2: 3 months after trauma accidents and to determine possible predictive factors to detect high- trauma risk patients in clinical practice. PDI IES-R IES-R THQ BDI-II BDI-II Hypothesis BDI-II

Patients can develop Posttraumatic Stress Disorders (PTSD) even if PDI: Peritraumatic Distress Inventory; THQ: Trauma History Questionnaire; – they are only slightly injured after a traffic accident. The subjective BDI-II: Beck Depression Inventory; IES-R: Impact of Event Scale Revised. experience of the accident seems to be mainly relevant to the devel- Peritraumatic Distress Inventory (PDI) [15] opment of an affective disorder like PTSD – regardless of the severity of the injuries. The PDI is used to estimate the individual experienced distress directly during or immediately after the traumatic event [15]. The 13- Methods items test concerns fear or helplessness and physical response reactions. A result of 23 points or more is considered as critical threshold [16]. Study population Trauma History Questionnaire (THQ) [17] Adult trauma patients (18–65 years) with minor injuries (Injury ffi Severity Score: ISS < 16 [12]) after road tra c accidents were in- This 24-items questionnaire is used to examine individual experi- cluded in this prospective cohort study. Trauma room patients were ences with potentially traumatic events like crime, general disaster and excluded. sexual or physical assault prior to the accident using a yes/no format For inclusion, the patients had to remember the sequence of events [17]. As the THQ is considered to be a history data collection instru- and the cause of accident. The Glasgow Coma Scale (GCS) [13] had to ment, the THQ has a qualitative result and there is no standard scoring fl be 15 at all times. Patients under the in uence of drugs or alcohol and method. ones who lost consciousness, had to be intubated or with Intensive Care Unit (ICU) stay after trauma, were excluded. Table 1 summarizes the in- Impact of Event Scale – Revised (IES-R) [18] and exclusion criteria. In total 69 patients met the in- and exclusion criteria. Due to in- The IES-R is a screening instrument for PTSD and consists of 3 complete data (participation declined, missing accessibility, contra- components: intrusion (7 items), avoidance (8 items) and hyperarousal (7 dictory information in the questionnaires) 33 patients were not avail- items) [18]. Based on a formula published by Maercker and Schützwohl able for follow-up. In total, 36 patients were included in this study. [19], a cumulative score can be formed from the three components to estimate the probability of developing a PTSD. The single dimension Data collection values lie within a range of 0–35 points and the total score is calculated from the dimensions following a rather non-linear principle. In case of In this prospective cohort study data collection was performed values higher than 0.0, PTSD can be expected. It should be noted that within 4 days, 6 weeks and 3 months after trauma [10]. Immediately IES-R is a screening tool to facilitate the assessment of typical PTSD after trauma (t0) demographic and accident-specific data were re- symptoms and cannot be used to determine the actual existence of corded. Additionally, the Peritraumatic Distress Inventory (PDI), the PTSD. Nevertheless, a high degree of intercorrelation and internal Trauma History Questionnaire (THQ) and the Beck Depression In- consistency have been reported for this questionnaire [20,21].Different ventory (BDI-II) were collected. After 6 weeks (t1) and 3 months (t2) studies describe the IES-R as an appropriate tool for PTSD screening the patients had to complete the Impact of Event Scale – Revised (IES-R) with a high predictive value [19,22–24]. and the BDI-II. The questionnaires used are explained below. Table 2 shows the timetable for data collection and questionnaire. Beck Depression Inventory-II (BDI-II) [22]

Demographic and accident-speciﬁc questionnaire The Beck Depression Inventory-II is a widely used self-report measurement tool to examine the severity of depression in adolescents and Age, sex, graduation, current employment situation, medical history adults. The 21-item self-report inventory indicates severity of depres- including psychological disorders and regular medication and drug or sion, with higher scores indicating greater depression. Values from 14 alcohol consumption were collected. Additionally, details concerning to 19 points indicate a mild, 20 to 28 points a moderate and 29 to 63 the accident, the injury pattern (Maximum Abbreviated Injury Scale points a severe depression [22,23]. (MAIS) [14]; Injury Severity Score (ISS) [12]) as well as the estimation of recovery chances and the issue of guilt were recorded. Ethical considerations

Table 1 The study has been approved by the Ethics Committee of the In- and exclusion criteria. University of Regensburg (number 16-101-0113). The study database was completely anonymized at the end of the investigation. Inclusion Exclusion

18–65 years GCS < 15 Statistical analysis ISS < 16 Anterograde or retrograde amnesia Road traffic accident Unconsciousness All analyses were performed by using IBM SPSS Statistics 22.0 (IBM fl Full memory of the accident In uence of drugs or alcohol Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Intubation ICU stay Armonk, NY: IBM Corp.). A p-value < 0.05 was considered statistically significant. The results were evaluated by t-test for paired samples to ISS: Injury Severity Score; GCS: Glasgow Coma Scale; ICU: Intensive Care Unit. detect differences between t1 and t2 after determining the distribution

2 K. Angerpointner, et al. Medical Hypotheses 135 (2020) 109465

Table 3 Patient characteristics.

n Age [mean ± SD] Sex MAIS ISS [mean ± SD] [mean ± SD]

36 39.8 ± 16.0 ♀ 9 (25%); ♂ 1.9 ± 0.8 4.9 ± 3.8 27 (75%)

MAIS: Maximum Abbreviated Injury Scale; ISS: Injury Severity Score. was appropriate for parametric testing. Using ANOVA with repeated measurements, diﬀerences between the three measurement points were calculated.

Results Fig. 1. Results of IES-R questionnaire: Correlation of calculated total values at Study population and demographics t1 (horizontal axis) and t2 (vertical axis); Red circles highlight the two patients with critical measurement values at t1. (For interpretation of the references to In total 36 patients were included into this prospective cohort study. colour in this ﬁgure legend, the reader is referred to the web version of this Demographic characteristics and details on injury severity are shown in article.) Table 3. Table 5 Questionnaires Results of Beck Depression Inventory-II (BDI-II).

Peritraumatic Distress Inventory (PDI) t0 (immediate) t1 (6 weeks) t2 (3 months) Within the study population the mean PDI value was 14.5 ± 9.3 Mean ± SD 5.4 ± 5.3 4.4 ± 4.4 2.4 ± 3.9 points (1–36). Total score max. 18 points 16 points 17 points 27.9% (n = 10) of the evaluated patients exceeded the critical Total score = 0 [n (%)] 10 (27.8%) 14 (38.8%) 23 (63.9%) threshold of 23 points. 2 of the 10 patients (20%) also reported con- BDI-II at all three measurement times. spicuous values in IES-R score.

II (t0) while in the other patient with conspicuous IES-R values a total Trauma History Questionnaire (THQ) score = 0 in the BDI-II was detected. 41.7% (n = 15) patients had not yet experienced traumatic situa- tions. 58.3% (n = 21) reported at least one potential traumatic experience. The mean value of the THQ was 1.8 ± 2.0. Correlation of PDI and IES-R A positive correlation of PDI and IES-R at both measurement times, 6 weeks (t1) and 3 months (t2) after trauma could be detected (t1; Impact of Event Scale – Revised (IES-R) r = 0.45, p < 0.005, t2; r = 0.38, p < 0.022). The results are illu- The results of the IES-R questionnaire (subscales and calculated strated in Fig. 2. total score) are shown in Table 4. Six weeks after trauma 5.6% (n = 2) of the patients reported critical measurement values with total scores of 0.16 and 0.42. One patient subsequently underwent psychiatric treat- Correlation of depression (BDI-II) and IES-R fi ment. Three months after trauma, the threshold value was still ex- A signi cant correlation of BDI-II and IES-R after 6 weeks (t1; ceeded by the latter patient with a total score of 0.13 (Fig. 1). Regarding r = 0.69; p < 0.001) and 3 months (t2; r = 0.81; p < 0.001) could be the subscales, the highest mean values were found in intrusion, fol- detected. These results indicate a strong correlation of depression and lowed by hyperarousal and avoidance both 6 weeks and 3 months after PTSD. trauma. All IES-R mean values after 6 weeks were significantly higher fl than the respective mean values after 3 months (p < 0.001). Further- In uence of other variables fi more, a significantly positive correlation between the scores at t1 and t2 No signi cant correlation of age, sex, graduation, current employ- could be observed (r = 0.94, p < 0.001) (Fig. 1). ment situation, medical history, regular medication, drug or alcohol consumption and IES-R could be detected (p ≥ 0.05). Persons who had Beck Depression Inventory-II The results of the BDI-II questionnaire are presented in Table 5. The mean values significantly decreased over time (p < 0.001). The ma- jority of participants reported 0 points three months after trauma. One patient with a pathological value in the IES-R, showed 18 points in BDI-

Table 4 Results of IES-R questionnaire.

mean ± SD (min–max) t1 (6 weeks after trauma) t2 (3 months after trauma)

intrusion 7.1 ± 6.5 (0–28) 4.3 ± 6.1 (0–27) avoidance 4.3 ± 5.4 (0–19) 2.6 ± 4.9 (0–20) hyperarousal 4.5 ± 5.9 (0–25) 3.1 ± 5.6 (0–23) calculated total score −3.5 ± 1.1 (−4.4 to −3.8 ± 1.0 (−4.5 to 0.4) 0.1) Fig. 2. Correlation of PDI and IES-R after 6 weeks (orange) and 3 months (blue). ﬁ IES-R questionnaire (subscales and calculated total score) after 6 weeks (t1) and (For interpretation of the references to colour in this gure legend, the reader is 3 months (t2). referred to the web version of this article.)

3 K. Angerpointner, et al. Medical Hypotheses 135 (2020) 109465 already experienced previous traumatic events showed symptoms of a Limitations stress disorder after a traffic accident more frequently (p < 0.028). A connection to the number of previous traumatic events could not be Our study has several limitations which have to be mentioned. On found. Estimation of recovery chances and the issue of guilt did not the one hand, the collected data are exclusively based on self-reported correlate significantly with the IES-R (p ≥ 0.05). questionnaires which only act as screening tools for PTSD symptoms. An objective analysis and valid diagnosis of PTSD was therefore not possible. To ensure privacy and data protection, the final diagnoses of Discussion the patients were not recorded. On the other hand, the study period of 3 months is too short to detect “delayed new onset” PTSD which can To our knowledge, this study is the first to examine only slightly occur even 6 months after trauma. injured patients after a traffic accident for PTSD. Current PTSD research Finally, the number of participants is too small to make reliable focuses in particular on severely injured patients (ISS ≥ 16) or patients predictions or statements about PTSD after minor trauma. with long intensive care stays [2,10,11,16,24,25], while little is known As mentioned above, further studies with larger patient collectives about PTSD after minor trauma. The prevalence of PTSD in severely are needed to learn more about PTSD even in slightly injured patients. injured patients ranges from 4.7% up to 34% within the first three months [10,11]. PTSD after mild trauma is a largely unknown trauma Conclusion sequence, especially in the early phase, and is therefore currently un- derestimated by the attending physicians. The present study showed that symptoms of PTSD can also occur The results of our study point out that symptoms of PTSD can also after minor trauma. We found that peritraumatic distress and previous occur after minor trauma. In our collective 5.6% of the included pa- traumatic experience determine the extent of PTSD symptoms. Factors tients showed conspicuous values in IES-R, the PTSD screening tool like sex and age showed no correlation. The occurrence of PTSD should ff used in the present study. One participant su ered from these symp- be considered not only in severely injured patients, but also in slightly toms even 3 months after trauma. As the IES-R questionnaire is de- injured patients after road traffic accidents. signed as a screening-tool, the values can only predict the probability of developing a PTSD. However, former studies showed, that patients re- Declarations porting positive scores in the IES-R scales are more likely to be diag- nosed with PTSD [18,19,23]. In the present study, one patient with Ethics approval and consent to participate conspicuous values in IES-R subsequently underwent psychiatric treatment. The decrease in IES-R values over time suggests a reduction The study has been approved by the Ethics Committee of the of typical PTSD symptoms 3 months after trauma. Simultaneously, we University of Regensburg (number 16-101-0113). Data anonymity is could observe a strong positive correlation among total scores, both guaranteed. Only patients who agreed to participate the study by giving 6 weeks and 3 months after trauma. The score after 6 weeks could their written content were included. therefore be predictive for the score after 3 months and it seems un- likely, that patients with a low total score 6 weeks after trauma will report higher scores 3 months later. Consent for publication It should be noted, that the occurrence of the so called “delayed new onset” PTSD, emerging more than 6 months after trauma, cannot be Not applicable. detected in this study with a limited follow-up of 3 months. Even though no patient showed an increase in IES-R scores over time, the Availability of data and material occurrence of PTSD symptoms after the study period remains possible [26]. Furthermore, our results show a positive correlation between the Not applicable. degree of depressiveness and posttraumatic stress symptoms. This fi fi nding con rms former studies, that already demonstrated the co- Funding morbidity of depression and PTSD [27,28]. ff fl In addition, di erent factors seem to in uence the increased psy- Not applicable. chological stress level after road traffic accidents. Our results show that the perceived intensity of stressful experience during the critical event Authors’ contribution could be a predictor for manifestation of PTSD symptoms. Due to the high correlation of PDI and IES-R scores, both might be reasonable Participated in the idea, planning, data analysis and interpretation, indicators for PTSD which has been postulated in previous studies [29]. statistical analysis and writing the manuscript: MK, HS, TH, AE, KA, Especially immediately after trauma the PDI might be a suitable SW. Participated in data interpretation and writing the manuscript: MK, screening tool to detect PTSD, even in slightly injured patients. Further AE, TH, KA. Participated in data acquisition: AE, HS, KT, SW. Have read studies with larger patient collectives will be needed to evaluate the and approved the final version: KA, SW, TH, KT, HS, AE, MK. quality of the PDI as screening tool for PTSD. All authors read and approved the final manuscript. In contrast to other studies, age and sex were not correlated with the IES-R score. However, previous studies mainly focused on severely injured patients [8,30]. Declaration of Competing Interest The analysis of correlation between previous trauma and PTSD fi showed that the occurrence of previous trauma is related to high IES-R The authors declare that they have no known competing nancial fl scores. These findings agree with results of a former study [31].In interests or personal relationships that could have appeared to in u- contrast, the frequency of previous trauma did not affect IES-R scores. ence the work reported in this paper. The reason for this might be an individual rating of trauma severity, so type and frequency of previous trauma might not be good indicators for Acknowledgements PTSD. We would like to thank Esther Kiszler (Departement of Trauma Surgery, University Medical Center Regensburg), for language editing.

4 K. Angerpointner, et al. Medical Hypotheses 135 (2020) 109465

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